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Subject PSYCHOLOGY

Paper No and Title Paper No 15: clinical Psychology

Module No and Title Module No 24: Substance-Related Disorders (Part 1)

Module Tag PSY_P15_M24

TABLE OF CONTENTS

1. Learning outcomes
2. Defining Substance-Related disorders
2.1 Clinical Description, Prevalence, and Effects of Substance-Related
Disorder.
2.2 Substance Use
2.3 Intoxication
3. Substance abuse
3.1 DSM-IV-TR Diagnostic criteria for substance abuse
4. Substance dependence
4.1 DSM-IV-TR Diagnostic criteria for substance dependence

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4.2 Diagnostic issues
4.3 Depressants
4.4 Stimulants
4.5 Opiates
4.6 Hallucinogens
4.7 Other drugs of abuse
5. Depressants
5.1 Alcohol Abuse and dependence
5.2 Prevalence and cost of Alcohol Abuse and Dependence
6. The clinical picture of alcohol and dependence
6.1 Short term effects of alcohol
6.2 Long term effects of alcohol
6.3 Psycho-social effects of alcohol abuse and dependence
6.4 Psychoses associated with severe alcohol abuse
7. Biological factors in the abuse of and dependence on alcohol
7.1 The neurobiology of addiction
7.2 The genetic vulnerability
7.3 Genetic influences and learning
7.4 Psycho-social factors in alcohol abuse and dependence
7.5 Failure in parental guidance
7.6 Psychological vulnerability
7.7 Stress tension Reduction and reinforcement
7.8 Expectations of social success
7.9 Marital and other intimate relationships
7.10 Socio-cultural factors
8. Treatment of alcohol abuse
8.1 use of medication in treating alcohol abusers
8.2 Medication to block the desire to drink
8.3 Medication to reduce the side effects of acute withdrawal
8.4 Psychological treatment approaches
8.5 Group therapy
8.6 Environmental intervention
8.7 Behavioral and cognitive behavioral therapy
9. Summary

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1. Learning Outcomes
 Know substance related disorders and differentiate between substance dependence and abuse.
 Identify the prevalence and clinical picture of alcohol abuse and dependence.
 Evaluate treatment of Alcohol Abuse Disorder

2. Defining Substance-Related Disorders

Substance related disorders are related to the misuse of psycho-active substance or drugs. People use
various substance to reduce physiological pain and alter the state of consciousness. Many people have
tried to quit smoking and some people are not get through the day without several drinks of alcohol and
beer. Smoking, alcohol and drugs affect the central nervous system of the individual. It relieves their
tension and give them happiness and euphoric feelings. Substance abuse is a maladaptive patterns of
substance use, it brings significant impairment in the daily functioning of the individual. Repeated use of
substance brings negative effects in social relationships and recurrent legal problems related to substance.
Despite these problems, their initial effects are pleasing and this seems the root cause of substance related
disorders.

2.1 Clinical Descriptions, Prevalence, and Effects of Substance-Related Disorders:

Prevalence of alcoholism varies, ranging between 1 and 550/1000. Bang and Bang (1991) studied that in
104 villages of Gadchiroli district of Maharashtra, 100,000 men consume alcohol and one fifth are
addicts. In a recent study conducted by ICMR-CAR-CMH,1990 in Bangalore, 1.2% of men suffering
from alcohol abuse. The meta analysis by Reddy and Chandra-shekar revealed prevalence of 6.9/1000 for
India with urban and rural rates of 5.8 and 7.3/1000 population. The rates among men and women were
11.9 and 1.7 respectively. In a community based study conducted by Gururaj in four area, rural, semi-
rural, slum and urban-habitual alcohol users accounted for 9%. He found that 10 to 60% of school
students, medical personnel and industrial workers use alcohol. He said that due to the high consumption
of alcohol, rate of hospital admission is increasing. The prevalence of alcohol use among women is found
to be 0.5%. due to the high consumption of alcohol, road accidents are increasing. They cause harm to
themselves.
First we need to outline that what we mean by substance use, substance intoxication, substance abuse, and
dependence. The term substance refers to chemical compounds that are ingested to alter mood or behavior
. Although you might first think of drugs such as cocaine and heroin, this definition also includes more
commonplace legal drugs such as Alcohol, the nicotine found in tobacco, and the caffeine in coffee, soft
drinks and chocolate. These so called safe drugs also affect mood and behavior, they can be addictive. To

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understand substance-related disorders, we must first know what it means to ingest psychoactive
substance-which alters mood, behavior, or both-to become intoxicated or high, to abuse these substance,
and become dependent upon or addicted to them.

2.2 Substance Use:

Substance use is taking psychoactive drugs or substance in an appropriate amount and it has not harmful
impact on the daily functioning like going to college, to office and social relationships. Drinking a less
quantity of alcohol, taking a cup of coffee in the morning and smoking a cigarette to relax and occasional
use of illegal drugs are example of substance use.

2.3 Intoxication:

Intoxication is our biological reaction to ingest substance or getting high, is referred to as intoxication.
Level of intoxication depends on how much the drug is taken and the Individuals physiological reaction.
Common physiological reactions towards intoxication are impaired perception, judgment, variation in
mood and motor ability.

3. Substance Abuse
Substance abuse is pathological misuse of a substance such as illegal drugs, alcohol and nicotine. The
individual is involved in potentially harmful behavior such as driving dangerously after having a high
quantity of alcohol and is always using it despite continuous psychological, social and health problems.

3.1 DSM-IV-TR Diagnostic Criteria for Substance Abuse:

A) A maladaptive pattern of substance use leading to clinically significant impairment or distress, as

manifested by (one or more) of the following, during the same 12-month period:

1. Recurrent substance use resulting in a failure to fulfill major role obligation at work, school, or
home( e.g; repeated absence or poor work performance related to substance use; substance related
absences, suspensions, or expulsion from school; neglect of children or household)
2. Recurrent substance use in situations in which it is physically hazardous (e.g driving an auto-
mobile or operating a machine when impaired by substance use)
3. Recurrent substance related legal problems (arrests for substance related disorderly conduct)
4. Continued substance use despite having persistent or recurrent social or interpersonal problems
caused by the effects of substance (arguments with spouse about consequences of intoxication, physical
fights)

B) The symptoms have never met the criteria for substance dependence for this class of substance.

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4. Substance Dependence
Substance dependence is addiction of drug and it is extremely difficult to give up it. The individual is
physiologically dependent on the drug, he needs the drug in much more quantity to have the same kind of
impact (tolerance) and physiologically behave in a negative way, if the drug is not provided to him
(withdrawal).Tolerance and withdrawal are response of the individual towards the drug being ingested. If
the person is given coffee in the morning, he starts experiencing headache. He may be going through the
caffeine withdrawal. Vomiting, nausea, aches, fever and diarrhea are withdrawal symptoms. Some drugs
have not any withdrawal symptoms, when you stop consuming them. These drugs are marijuana or LSD.
Cocaine withdrawal has pattern that includes anxiety, lack of motivation, and boredom.

4.1 DSM-IV-TR Diagnostic Criteria for substance dependence:

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as

manifested by three (or more) of the following, occurring at any time in the same 12-month period:
1) Tolerance as defined by either of the following;
a) A need for marked increased amounts of the substance to achieve intoxication or desired effects
b) Marked diminished effect with continued use of the same amount of the substance
2) Withdrawal, as manifested by either of the following;
a) The characteristic withdrawal syndrome for the substance ( refers to criteria A and B of the criteria
sets for withdrawal from the specific substance)
3) The substance is often taken in larger amounts or over a longer period than was intended.
4) There is a persistent desire or unsuccessful effort to cut down or control substance use
5) A great deal of time is spent in activities necessary to obtain the substance (visiting multiple doctors,
driving long distances) use the substance ( e g chain smoker) or recover from its effects.
6) Important social, occupational, or recreational activities are given up or reduced because of substance
use.
7) The substance use is continued despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused by the substance.

4.2 Diagnostic Issues

In early DSM, alcoholism and drug abuse were not treated as separate disorders. Instead they were
categorized as “sociopathic personality disturbances” because substance use was seen as a symptom of
the problem. It was considered as a sign of moral weakness and influence of genetic and biology was
hardly recognized.
The DSM-IV term substance related disorders indicates several subtypes of diagnoses for each substance,
including dependence, abuse, intoxication, withdrawal, or a combination of these. These distinctions help
clarify the problem and focus treatment on the appropriate aspect of the disorder.
Substance can be grouped into five general categories:
 Depressants

 Stimulants
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 Opiates

 Hallucinogens

 Other drugs of abuse

4.3 Depressants:

Depressants are those drugs which induce relaxation and behavioral sedation. These include hypnotic
drugs like benzodiazepines and barbiturates, alcohol and sedative drugs.

4.4 Stimulants:

Stimulants make us more active and enhance our mood. Caffeine, cocaine, nicotine and amphetamines are
stimulant drugs.

4.5 Opiates:

Opiates produces euphoric feelings and analgesia in the person. Morphine, opium, codeine are opiates.

4.6 Hallucinogens:
The effects of hallucinogens are delusion, hallucinations. It also alters sensory perception of the
individual.

4.7 Other Drugs of abuse:

Substances which do not come under single category are inhalants, steroids and prescription medications.
These drugs produces various kinds of psychoactive effect.

5. Depressants
Depressants suppress the central nervous activity. It reduces the physiological arousal and induces
relaxation. Anxiolytic drugs, sedatives and alcohol are depressants.

5.1 Alcohol abuse and dependence:

Alcohol abuse and alcohol dependence are two different disorders. The symptoms of Alcohol abuseare
social withdrawal like marital disruption, deprivation from family, disharmony with friends and
occupational effects such as absenteeism from office. They do not show tolerance and withdrawal
symptoms. Individuals who are dependent on alcohol show severe symptoms such as withdrawal or

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tolerance. The major effects of dependence are anxiety, depression and sleeplessness. Alcohol is a
depressant but its initial effects are stimulation. Initially, alcoholic belief that it will reduce tension and
increase social competence. Alcohol depresses certain areas of brain, their cognitive abilities are affected.
Their judgment and motor co-ordination becomes impaired, their reaction time is slowed. They come
across major road accidents.

5.2 Prevalence and cost of Alcohol Abuse and dependence:

Alcohol is especially frequent among college age adults. In a survey conducted by Mohan et.al (1992) in
Delhi, found that 26% of residents living in Delhi slums were substance abuse, the majority involving
alcohol. In another survey conducted in or around Bangalore by ICMR-CAR-CMH, 1.2% of men were
found to suffer from alcohol dependence syndrome. The prevalence rate among men is found to be more
than women. Estimates suggest that 20 to 30% hospital admission is related to alcohol consumption.More
men than women died in alcohol related accidents.

6. The Clinical Picture of Alcohol and Dependence

There are many common physiological consequences of alcohol. They face cognitive deficits like
forgetting, nausea, fatigue, hangover and headaches. They have disastrous family life. They face many
social and health problems.

6.1 Short Term Effects of Alcohol:

when an individual consumes alcohol, it passes through small intestines and is absorbed into blood. Then
it is broken down into liver. Alcohol absorbs very quickly into the system and its removal is slow. It
effects the central nervous system of the brain and neurotransmitters, especially GABA, which reduces
the tension of the person. It also increases the secretion of serotonin and dopamine. It increases the
pleasure feeling in the person. Alcohol inhibits the glutamate receptors, which is responsible for memory
loss and deficits in thinking.

6.2 Long Term Effects of prolonged Alcohol Abuse:

There are many adverse effects of prolonged use of alcohol on each tissue and organ of the individual. It
provides empty calories to the person and reduces his appetite. It do not provide any nutrition to the body.
It impairs the digestive system of the person and reduces his capacity to absorb vitamins. Deficiency of
vitamin B complex may bring amnestic syndrome. Severe loss of recent and long term memory occurs in
the person. Long term use of alcohol bring protein deficiency and further contribute to the development of
liver cirrhosis. Long term use of alcohol damages heart, pancreas and hemorrhages.
In elderly people, it can cause amnesia, which can cause a severe memory loss. Individuals, who have
chronically abused alcohol consume less quantity of protein leads to the development of liver cirrhosis.
Alcohol effects the endocrine glands, heart, pancreas, hypertension and stroke. It also damages some parts
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of the brain. Heavy use of alcohol impairs memory. Mothers who consume alcohol during pregnancy
gives birth to infants of mental retardation. Even the moderate amount of alcohol taken during pregnancy
effects the growth of fetus.

6.3 Psychosocial Effects of Alcohol abuse and dependence:

In addition to various physical problems, an excessive drinker suffer from chronic fatigue, oversensitivity,
and depression. The excessive use of alcohol eventually becomes counterproductive and can result to
counterproductive and can result in impaired reasoning, poor judgment, and gradual personality
deterioration. Behavior typically becomes generally touchy, irritable, and unwilling to discuss the
problem.

6.4 Psychoses associated with severe Alcohol Abuse:

Individuals who consumes large quantity of alcohol suffer from delirium.

 They suffer from disorientation for place and time.

 Hallucinations are found in them, particularly of small, fast moving animals like snakes ant rat.
 Acute fear
 Extreme suggestibility, in which a person can be made to see almost any animal if its presence is
merely suggested
 Marked tremors of the hands, tongue and lips
 Other symptoms include perspiration, fever, a rapid and weak heartbeat, a coated tongue, and foul
breath.
The delirium typically last from 3 to 6 days and is generally followed by a sleep. A second alcohol related
psychosis is the disorder referred to as amnesia. Persons with these disorder may not recognize pictures,
faces, rooms, and other objects are familiar.

7. Biological Factors in the Abuse of and Dependence on Alcohol:

Biological and psycho-social factors contribute to the development of alcohol abuse and dependence.
Many research view alcohol abuse as maladaptive pattern of adjustment to the stressful life events. Some
researchers emphasized sociocultural factors like availability of alcohol and approval to it leads to alcohol
dependency. The development of alcohol addiction is a complex process involving many elements-
constitutional vulnerability and environmental encouragement as well as the unique properties of certain
psycho-active substance.

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7.1 The Neurobiology of addiction:

Alcohol produces euphoria by stimulating mesocortico limbic dopamine pathways( MCLP) in the brain.
This neuronal system is involved in functions such as control of emotions, memory and gratification.
Alcohol produces euphoria by stimulating this area in the brain.

7.2 The Genetic vulnerability:

The possibility of genetic predisposition to developing alcohol abuse problem has been widely
researched. Many experts today agree that genetic plays an important role in developing sensitivity to
alcohol. Alcohol clearly runs in the families. Research has shown that some people such as sons of
alcoholic who were adopted by other non-alcoholic families has also provided useful information. Genetic
alone is not the whole story, and the exact role it plays in the development of alcoholism remains unclear.
This issue continues to debate and some researchers are clear about the primary role of genetics in
alcoholism. Although some genetic factors are implicated in the etiology of alcoholism but it is not clear
that genetic alone will account for the full range of alcohol.

7.3 Genetic Influences and learning:

Genetic factors along with learning leads to the development of alcohol abuse and addiction. The
individual is exposed to the environment where he gets sufficient quantity of alcohol before he gets
addicted to it. He is living in the family where initial as well as prolonged use of alcohol was promoted.
People become conditioned to alcohol and tends to respond in a particular way as a result of learning.

7.4 Psycho-social causal factors in Alcohol abuse and dependence:

Person of alcohol addiction is not only physiologically dependent on it but also psychologically. A
number of psycho-social factors leads to alcohol abuse and dependence.

7.5 Failure in Parental Guidance:

It was found that dysfunctional family relationships are implicated in the abuse and dependence on
alcohol. Children whose parents are addicted to alcohol they are vulnerable to developing alcohol abuse
themselves. Warm and stable family relationships are important in the healthy development of children.
Children who are exposed to negative life events and circumstances. They are vulnerable to developing
alcohol abuse. Their elders at home do not provide them any guidance, they tend to get involved in
maladaptive behavior such as alcohol abuse and addiction.

7.6 Psychological Vulnerability:

Researchers have found that psychological factors leads to alcohol abuse. Some alcoholic are found to be
emotionally immature. They react to their failures with inferiority. They are found to be impulsive and
aggressive. They require an inordinate amount of praise. They are unsure about their abilities.
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7.7 Stress Tension Reduction, and Reinforcement:

Alcoholic drink as it reduces their stress and tension. They are found to be dis-satisfied with their life.
Alcohol induces positive affect in the alcoholic and it works as a reinforcement.

7.8 Expectations of social success:

Young alcoholic start drinking alcohol under peer pressure and they become famous among them.
Expectations play an important role both in the initial start and maintenance of drinking. They expect that
it will reduce their stress and anxiety and increase the pleasure feeling in them.

7.9 Marital and other intimate relationships:

Person with marital problems and less intimate relationship tend to develop drinking alcohol. Excessive
drinking starts during the problems in marital and intimate relationships. Break-up of marital relationship
is highly stressful for some persons. The stress of divorce leads to increased alcohol abuse.

7.10 Socio-cultural Factors:

Alcohol use is a pervasive component in the social life in western civilization. Social events revolve
around alcohol use, and alcohol use before and during meals is commonplace. People consume alcohol
because it enhances euphoric feelings and reduces their stress. Researchers have found psychological and
socio-cultural factors in the high intake of alcohol. Cultural factors has effect on the consumption of
alcohol. Muslims and orthodox Jews religious values prohibits the use of alcohol. The incidence of
alcohol is less among these people. Alcohol consumption is maximum among Europeans. France has the
highest rate of alcoholism in the world.

8. Treatment of Alcohol-Abuse Disorders

Individuals suffering from alcohol abuse are difficult to treat. Some of them leave the treatment in
between and others refuse to admit that they have some problem. Treatment includes detoxification,
physical rehabilitation, changing the thought process of the person that he can lead more useful life
without taking alcohol. Medication, behavioral and psychological strategies are used to treat patients of
alcohol abuse.

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8.1 Use of Medication in treating Alcohol Abusers:

Biological approaches include a variety of treatment measures such as medications to reduce craving, to
ease the detoxification process and to treat co-occurring health and mental health problems that may
underlie the drinking behavior.

8.2 Medications to block the desire to drink:

Antabuse a drug that causes violent vomiting when followed by ingestion of alcohol, may be
administered to prevent an immediate return to drinking. Medication is not proved to be effective in
treating alcoholism because it has uncomfortable side effects. Another medication is Naltrexone. It is
proved to be helpful in reducing the craving for alcohol by blocking the pleasure producing effects of
alcohol.

8.3 Medications to reduce the side effects of Acute Withdrawal:

Medicines are given to the individual to reduce the severity of withdrawal symptoms such as headaches
and sleeplessness. Benzodiazepines are prescribed to the patient to treat the withdrawal symptoms. It may
introduce addiction to some other substance. Detoxification is also used to treat acute withdrawal.

8.4 Psychological Treatment Approaches:

Detoxification is optimally followed by psychological treatment including family counseling and the use
of community resources related to employment and to other aspects of a person’s social readjustment.
Psychological treatment consists of CBT, environmental treatment and group therapy.

8.5 Group therapy:

Spouse and children of the alcoholic abuser may be invited to join in group therapy. Family members
take the responsibility for co-operating in treatment. Such treatment also help them see new
responsibilities, such treatment also helps them see new possibilities for coping with circumstances that
have led to their difficulties.

8.6 Environmental Intervention:

Environmental variables proved to be successful in treating the alcoholic. Usually family members leave
them because of their alcohol addiction and abuse.

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8.7 Behavioral and cognitive behavioral therapy:

Behavioral and cognitive behavioral therapy is effective in treating the persons of alcohol addiction. In
aversive conditioning some noxious stimulus is given to the person with alcohol. This suppresses their
drinking habit. Alcoholic feel like vomiting after taking alcohol. Skill training is also used to treat young
alcohol abuser. The person is given knowledge about the intake of alcohol, skills are developed in
situations associated with increased risk of alcohol use and thoughts are modified.

9. Summary

Substance related disorders are extremely common disorders. They are related to the use of psychoactive
drugs. DSM-IV distinguishes between substance dependence and substance abuse. Dependence means the
person is physiologically dependent on the drug. He needs it in much more quantity to have the same kind
of impact. Alcohol is not only psychoactive substance but Smokers also develop nicotine dependence. It
brings psychological and physiological impairments in social, personal and occupational functioning.
Substance abuse has a variety of short term and long term effects on the individual. It includes poor
perception, disastrous family relationship, difficulty in managing financial resources and face problems at
a work place. Genetic and psychosocial factors play role in substance related disorders. Some common
factors that can lead teenagers to abuse alcohol, smoking and drugs are high level of stress, peer pressure
and disturbed relationships with the family.

PSYCHOLOGY Paper No 15: clinical Psychology

Module No 24: Substance-Related Disorders (Part 1)
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PSYCHOLOGY Paper No 15: clinical Psychology

Module No 24: Substance-Related Disorders (Part 1)